Sino-Nasal Disorders and Allergy

Sino-Nasal Disorders and Allergy

The goal of the UPMC Division of Sino-Nasal Disorders and Allergy is to accurately diagnose and create customized treatment and therapy for patients suffering from nose, sinus, and allergy problems in order to improve quality of life.

Nose and sinus problems are frequently associated with allergic rhinitis as well as other disorders such as asthma, sleep apnea, headaches, and impaired quality of life. To guarantee a comprehensive approach to the diagnosis and treatment of even the most complex disorders, the center's staff may consult with specialists in other fields such as asthma/pulmonology, immunology, neurology and the UPMC Sleep Center.

From the simplest nose and sinus problem to the most complex, our specialists provide patients with timely expertise.

Our Experts

The Division of Sino-Nasal Disorders and Allergy is part of the Department of Otolaryngology. Specialists in this division are experts in diagnosing and treating patients with nose and sinus symptoms. Patients may be referred to the division by a physician, or they may contact the division directly.

Doctors within the division treat sinusitis as well as other problems that can accompany the conditions including:

Allergic rhinitis

Asthma

Voice problems

Obstructive sleep apnea

Headaches

Nasal blockage

The division offers many different diagnostic services including allergy testing. It treats sino-nasal disorders with both medications and surgery, if necessary, and also treats allergies with allergy injections, sublingual allergy drops, education, and nutritional counseling.

When additional consultation is necessary the division works closely with the Comprehensive Lung Center and the Voice Center.

The Division of Sino-Nasal Disorders and Allergy consists of faculty members of the Department of Otolaryngology who have a special interest in the surgical and medical treatment of the nose and sinuses. Each member of the division has slightly different interests and expertise. Click on the doctors' names to read more about their specialties and backgrounds.

Experience your Exam on Screen

UPMC offers cutting-edge technology in the world of sino-nasal treatment with a minimally invasive and comfortable examination process that allows patients to experience their exams on a 17-inch monitor. This new technology uses a 30-degree scope (four millimeter endoscope) to provide a more detailed examination of patients’ ears, noses, and throats. The scope is inserted in the ear, nose, and/or throat and is painless. This technology also provides a less invasive alternative to the operating room when removing nasal polyps. The 30-degree scope makes the removal of nasal polyps an in-office procedure using local anesthesia. This scope also allows for the doctor to easily take nasal cultures testing for bacteria and fungi. This new technology also records the entire examination and procedure in order to keep a visual record of the patients’ progress and treatments. The 30-degree scope is just one example of the many patient services used by sino-nasal specialists to ensure a thorough and proper diagnosis and treatment plan.

Diagnostic Services

The Division of Sino-Nasal Disorders and Allergy uses the following tests and procedures to help diagnose sinus problems and recommend a course of treatment.

CT Scans of the Sinus

A computed tomography (CT) scan is the type of image preferred for analyzing the anatomy of the sinuses. At the Division of Sino-Nasal Disorders and Allergy, the physician always orders a CT scan before suggesting sinus surgery.

Video Nasal Endoscopy

An endoscope is a slender instrument with a video camera attached. The endoscope is inserted about three inches into the nose to enable the physician to see the drainage sites from the sinuses and the back of the nose (outflow tracts). Before endoscopy, the nose will be decongested and anesthetized. The anesthetic (lidocaine) spray will temporarily numb the throat. The procedure causes little discomfort, and patients may resume normal activities after the examination.

Mucociliary Transport Study

This test evaluates the ability of the lining of the nose to carry the mucus that cleanses the nose. Patients with abnormalities of the mucus or cilia, the normal microscopic structures that move the mucus within the nose, have increased nasal problems. Examples of patients with impaired mucociliary transport are those with cystic fibrosis, primary ciliary dysmotility syndrome, Kartageners syndrome, or repeated, prolonged infections. Mechanical cleaning of the nose with topical antibiotics and saline solution is important in treating this condition.

Sinus Secretion Aspiration

The pus draining from the sinuses is visualized with a slender telescope inserted into the nose and directly suctioned for culture. A specialist can determine what kinds of bacteria may be causing infection or inflammation. The specimen will be sent to the microbiology laboratory for microscopic analysis and culture. The patient will be informed of the results of the procedure within days, and the most appropriate antibiotic to treat the infection will be prescribed.

Allergy Testing

Allergy Testing: inhaled and contact allergies tests for allergic reactions to inhalants to determine if a person is allergic to an inhalant; that is, an allergen that can be inhaled, such as pollen, mold, cat dander, or dust mites; forms of skin testing known as prick testing and skin endpoint titration are performed. In this procedure, a minute amount of the suspected allergen is placed under the top layer of the skin on the upper arm. Skin-prick testing is used as a first screening and skin endpoint titration is used to determine how allergic the patient is.

Patch testing is used to determine the cause of a contact allergy; that is, an allergy that results after a person comes into contact with an allergen. Common causes of contact allergies are makeup and latex. A patch test is used to determine whether a substance that should not be injected into the skin; for example, metals such as nickel, causes an allergy. In a patch test, the suspected allergen is attached to a nonreactive backing, which holds the allergen against the skin for 48 to 72 hours.

Allergy Testing: Food Allergies

An adverse reaction to food can be categorized as either a food intolerance or food allergy. The main difference between these two is that food intolerance does not involve the immune system; a food allergy does. Food intolerance can usually be helped by some means, such as by taking a dietary enzyme supplement. The symptoms of a food allergy may be treatable, but the allergy itself may not be correctable.

A common example of food intolerance is that caused by lactose deficiency. A person with lactose deficiency experiences discomfort and other symptoms after eating dairy products because his or her body does not produce enough lactase, the enzyme needed to digest dairy foods. A person with lactose intolerance can address the problem by taking a lactase supplement. In contrast, an allergy to dairy products cannot be corrected by taking a supplement.

The eight most common food allergens cause more than 90 percent of all allergic reactions to foods. These common allergens are milk, eggs, peanuts, tree nuts, soy, wheat, fish, and shellfish.

Many tests for food allergy involve testing for immunoglobulin E (IgE). Immunoglobulins are proteins, most of which help protect the body from infection. IgE can be different. In about 20 percent of humans, IgE reacts against substances that are harmless, such as pollen grains, animal dander, and some food proteins. It is involved in causing allergic asthma and allergic rhinitis (hay fever) and, in many cases, the symptoms of sneezing, swelling, redness, and itchiness. People who suffer from allergies are those whose IgE reacts to allergens.

To diagnose food allergies, the Division of Sino-Nasal Disorders and Allergy uses:

Elimination challenge diets

Elimination diets are an essential part of diagnosing food allergies and are used to test reactions to foods that are not necessarily associated with high levels of IgE. In the diet, the patient will not eat a specific food for five days. If the patient is allergic to the withdrawn food, the period of abstinence makes him or her much more sensitive to it. On the sixth day, the patient is "challenged" with the food and will eat a small portion of it. Adverse symptoms, such as itching, gastrointestinal distress, facial pressure, or nasal congestion, indicate that the patient is allergic to the food.

In vitro testing, including radioallergosorbent (RAST) tests

In vitro testing is done outside a patient’s body. The division uses in vitro testing to detect allergies in patients who cannot undergo skin testing or who have a potentially life-threatening allergy, such as peanut anaphylaxis. It involves taking a blood sample from the patient and determining what kinds of IgE and how much of each kind are present to a particular tested food.

Skin tests

In a skin test, a small amount of a suspected allergen is placed under the top layer of the skin on the upper arm. If the skin shows a reaction, the patient is allergic to the substance.

Allergy Testing: Skin Testing

There are several methods of skin testing for allergies. The division uses both prick and intradermal dilutional testing that gives an accurate reading of the degree of allergy, and if allergy shots are to be given, allows the physician to initiate shots at the highest safe concentration. A small amount of antigen is injected under the top layers of the skin to make a small bump (4 mm) under the skin. If you are allergic, then this bump grows to a larger size in the next ten minutes. The size of this bump or welt is then measured after 10 minutes.

Full skin testing will take about two hours.

If you are a patient who will undergo allergy skin testing at the Division of Sino-Nasal Disorders and Allergy, view instructions on how to prepare for your testing appointment.

What to Do Prior to Your Allergy Skin Testing

All patients undergoing allergy skin testing must have been seen by a member of University Ear, Nose and Throat Specialists within the last six months.

Full skin testing will take about two hours. All skin testing appointments include an in-depth environmental allergy consultation and a thorough overview of the immunotherapy program. Wear a short-sleeved or sleeveless shirt and refrain from wearing perfume to the testing area. You may eat prior to allergy testing. Do not exercise vigorously before or after the testing, as it may increase the chance of a reaction.

Certain medications can change the results of your allergy tests. Before arriving for allergy testing, please note the following instructions.

1. Do not take aspirin or aspirin-containing products for 10 days prior to testing, if possible, to decrease bruising or bleeding during testing. However, if you are using aspirin for cardiac reasons or stroke prevention, you may continue to use the aspirin.

2. Do not take ibuprofen or ibuprofen-containing products (Advil, Motrin, Nuprin) for five days prior to testing to decrease bruising or bleeding. However, if you are using ibuprofen for cardiac reasons or stroke prevention, you may continue to use the ibuprofen.

3. The following common over-the-counter and prescription medications contain antihistamines and should be avoided for four days prior to your allergy testing:

Actifed

Allegra

Allegra-D

Allerest

Alka-Seltzer Cold & Sinus

Astelin

Atarax

Benadryl

Chlorpheniramine

Chlor-Trimeton

Claritin

Claritin-D

Comhist

CoTylenol

Deconamine

Dimetapp

Drixoral

Dramamine

Excedrin PM

Isoclor

Kronofed A

Kronofed A, Jr.

Marax

Midol PM

Motrin PM

Motrin Sinus

Naldecon

Nolahist

Novahistine

Nolamine

Nyquil

Optimine

Phenergan

Polyhistine

Rondec

Ru Tuss

Semprex D

Sominex

Tavist I

Tavist II

Teldrin

Tylenol PM

Tylenol Allergy/Sinus

Zyrtec

Cough drops with liquid centers

4. You cannot be allergy tested or receive allergy injections if you are taking non-selective beta-blockers, including topically-applied beta-blocks and combination diuretics:

Betapace (sotalol)

Blocadren (timolol maleate)

Brevibloc (esmolol HCL)

Cartrol (carteolol HCL)

Corgard (nadolol)

Inderal (propranolol)

Levatol (penbutolol sulfate)

Normodyne (labetalol HCL)

Trandate (labetalol HCL)

Visken (pindolol)

Zebeta or Ziac (bisoprolol fumarate)

Topically applied beta-blockers:

Betagan (levobunolol)

Betoptic (betaxolol)

Ocupress (carteolol)

Optipranolol (metipranolol)

Timoptic (timolol)

Combination diuretics with beta-blockers:

Corzide (nadolol-bendroflumethiazide)

Inderide (propranolol-hydrochlorothiazide)

Normozide or Trandate (labetalol-hydrochlorothiazide)

Timolide (timolol-hydrochlorothiazide)

You can be tested if you are taking the following selective beta-blockers:

Kerlone (betaxolol)

Lopressor (metoprolol)

Sectral (acebutolol)

Tenormin (atenolol)

Tenoretic (atenolol and chlorthalidone)

Please contact the Allergy Clinic at 412-692-2228 with any questions regarding the testing or restrictions.

All allergy testing is performed on the second floor of the Eye & Ear Institute, Suite 214.

Allergy Treatments

Education

Allergy treatment includes education about ways to decrease exposure to allergens in the environment. A patient troubled by dust mites, for example, would learn about the special mattress covers that are available to alleviate dust-mite problems and how often to do a hot-water wash of bedding.

Shots

If allergy shots are recommended, we determine the highest safe concentration at which shots should start. Only an allergist can make this determination and prepare the dose vial, which contains a mixture of the various allergens to which the patient is allergic. Some patients come to the division to get allergy shots; others go to their family physician.

The emphasis on starting at the highest safe concentration usually means that a patient is able to reach a maintenance shot schedule within six months to one year of starting allergy shots. If a patient's symptoms are not sufficiently improved after he or she starts maintenance shots, then allergy shots are stopped and the division staff pursues other kinds of treatment.

Sublingual Immunotherapy (SLIT)

SLIT is a common form of allergy desensitization used in Europe. Allergy drops are held under the tongue for a minute and swallowed. The risk of an adverse reaction is less with SLIT than allergy shots. After the initial dose patients receive daily SLIT at home. Currently many insurance companies do not cover SLIT.

Nutrition Counseling

Because food allergies often play a role in sinus problems, the Division of Sino-Nasal Disorders and Allergy offers instruction in performing an elimination/challenge diet as well as skin testing for food allergies.

Treatment for Sinus Disorders

The Division of Sino-Nasal Disorders and Allergy uses several categories of medications to treat sinusitis.

Mucus Thinners

Thick postnasal discharge is a common allergy symptom. A mucus thinner allows the mucus to drain better by thinning it so that the patient is less aware of the discharge. Having postnasal discharge is not abnormal. The average person's nose and sinus cavities produce as much as a liter of discharge each day. The discharge is transported as a thin mucous blanket to the back of the nose. The mucus usually goes down the throat during swallowing. Staying well hydrated is quite important in making sure that mucus drainage does not become too thick.

Antihistamines

The body releases histamine during an allergy attack. Histamine causes sneezing, itching, and welting. An antihistamine blocks allergic reactions by blocking histamine receptors. Older antihistamines are associated with more side effects than the newer antihistamines, which include ceterizine (Zyrtec), desloratadine (Clarinex), fexafenadine (Allegra), and loratadine (Claritin). The side effects of older antihistamines include performance impairment, drowsiness, dry mouth, and occasionally urinary retention. The newer antihistamines have a very low incidence of any side effect and in particular do not cause drowsiness, except for ceterizine, which may impair performance or cause sedation, but much less frequently than the older antihistamines.

Leukotriene Modulators

Leukotrienes are potent agents of broncho constriction. Medications such as montelukast (Singulair) are effective for both asthma and allergic rhinitis. Not every patient responds with symptom relief. Frequently a trial of four days of medication is utilized to determine whether a particular patient’s allergic rhinitis or asthma will respond to drugs such as montelukast. Zileuton is indicated for asthma and sometimes used in conjunction with montelukast. Patients whose symptoms improve with zileuton undergo monitoring of their liver functions monthly for at least three months.

Decongestants

Decongestants relieve nasal congestion by narrowing the blood vessels, which decreases congestion in the nasal membranes. Decongestant nasal sprays give prompt relief, but can only be used for three or four days before they start to cause rebound swelling. Pseudoephedrine, a decongestant, is now found behind the counter. Phenylephrine is less effective than pseudoephedrine. All oral decongestants can cause side effects such as urinary retention, insomnia, and jitteriness.

Nasal Sprays

All nasal sprays work best if directed into the nose and slightly tilted toward the outside or lateral portion of the nose. Do not direct the nasal spray toward the center of the nose or septum as this increases the chance of irritation and nosebleeds.

The two most commonly prescribed nasal sprays are steroid nasal sprays which may take several days to become maximally effective and antihistamine sprays, which work more rapidly, sometimes within 15 minutes. Both of the sprays relieve a wide variety of nasal symptoms, including congestion, sneezing, itching, and drainage. Some patients require use of both sprays together to get maximal relief.

Nasal Steroid Sprays

There are many different nasal steroid sprays available. For most patients all are equally effective, although occasionally an individual patient may do better with one particular product. Most nasal steroid sprays do not cause any detectable change in the body. The newest nasal steroid sprays, such as mometasone fuorate, fluticasone fuorate, or propionate, have the lowest detectable systemic levels and are usually recommended when children require a nasal steroid spray.

Antihistamine Nasal Sprays

Unlike oral antihistamines which only treat sneezing and itch, antihistamine nasal sprays are also effective for congestion. Side effects of Azelastine include occasional bitter taste and rare cases of drowsiness. The occasional bitter taste some patients experience with Azelastine can be minimized by leaning forward, directing the spray laterally into the nose, and not sniffing for a few minutes.

Decongestant nasal sprays are available over-the-counter and include medication such as Neo-Synephrine and oxymetazoline (Afrin). These medications should not be used for more than three or four days consecutively because the patient may develop rebound congestion. This “addiction” to the decongestant sprays does occur with prescription nasal sprays and may be minimized if the decongestant spray is used in conjunction with nasal steroid sprays.

Saline nasal sprays which are also over-the-counter, are effective for moisturizing the nose and to reduce the incidence off nose bleeds which occur because of dryness.

Nasal Rinses

Irrigation of the nose and sinus cavity with any of several commercial nasal saline rinses can be very helpful in removing mucus and crusts. If nasal rinses are used they should precede with the application of prescription nasal sprays. Patients can also make their own nasal rinses by mixing 1 ½ teaspoons of salt, 1 tsp. baking soda in 1 qt. of sterile water. There are a variety of irrigation devices available, including the Netie Pot, baby bulb syringes, and water picks. It is important that any device used be cleaned every few days to prevent the growth of mold or bacteria. Patients with cystic fibrosis may benefit from increasing the salt content of the saline wash so that it is hypertonic. This means mixing 3 tsp. of salt to a quart of water.

Topical Antibiotic and Antifungal Rinses

Depending on the bacteria found on the culture from your diagnostic testing and the sensitivities of the bacteria found to antibiotics, a customized antibacterial wash, may be recommended and prescribed. Frequently for staph aureus infections, mupirocin (Bactroban) 5g in 45cc of saline is recommended as a spray or wash. For Pseudomonas infection, gentamicin 80mg per 500cc of saline is recommended. If fungus is detected, then amphotericin B. irrigations may be recommended.

Antibiotics

Antibiotics help fight bacterial infections. Antibiotics are useful in treating bacterial sinus infections but will not help a cold caused by a virus. Many bacteria that were once treatable by common antibiotics have developed resistance, so antibiotics are carefully prescribed to treat sinus problems. A culture of the bacteria found in the sinuses will provide guidelines to the best antibiotic to use. It may help you while taking an antibiotic to replenish the good bacteria in your system by either taking probiotics, acidophilus tablets, or eating foods such as yogurt or kefir that contain large amounts of benign bacteria.

Surgical Treatments for Sinus Disorders

Septoplasty

Septoplasty corrects a deviated septum with no, or minimal, change in the outward appearance of the nose. It is performed when a patient has constricted nasal breathing because of a septal obstruction.

Coblation of the Inferior Turbinates

Coblation is an in-office procedure that reduces the size of the turbinate, the structures that swell up from either side of the nose and can block the airway and impair breathing. Numbing the nose takes about 15 minutes, and the procedure itself takes 10 minutes. The patient waits for 10 to 15 minutes after the procedure to ensure that no bleeding will occur. After a coblation, most patients return immediately to work or regular activities.

Rhinoplasty

Rhinoplasty changes the outward structure of the nose. Sometimes the procedure is necessary to allow the inside of the nose to work properly. For example, a patient with a severely fractured nose may need a rhinoplasty to resolve an airway obstruction. In other cases, the procedure is cosmetic. Some rhinoplasties are performed while the patient is completely asleep (anesthetized); in others, the patient is under "twilight" anesthesia. In either case, rhinoplasty is an outpatient procedure.

Endoscopic Sinus Surgery

An outpatient procedure, endoscopic sinus surgery (ESS) is used to correct structural abnormalities of the nose and sinuses. The surgeon uses an endoscope, a slender instrument with a video camera attached, to guide the surgical instruments. This type of surgery may be performed to relieve chronic sinusitis if medical treatments have been ineffective. ESS is also used to remove nasal polyps. Polyp surgery can be done in the office after an anesthetic is applied to the nasal membranes. The polyps are removed by a microdebrider, a hollow rotating suction that cuts tissue and suctions it away. After nasal polyp removal, the patient is usually able to return immediately to normal activities. Other outpatient ESS procedures require a longer recovery time.

Contact Us

The Division of Sino-Nasal Disorders and Allergy is located on the second floor of the UPMC Eye & Ear Institute.

For help in finding a doctor or health service that suits your needs, call the UPMC Referral Service at 412-647-UPMC (8762) or 1-800-533-UPMC (8762). Select option 1.

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